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Health Care Coverage, Capacity and Cost: What Does the Future
A Report from America's Internists on the State of America's Health
Senior Vice President, Governmental Affairs and Public Policy
American College of Physicians
I am pleased to join Dr. Ralston in presenting our ideas for
common ground solutions to the three biggest challenges facing
American health care, which are to ensure that:
Everyone has affordable coverage;
Everyone has access to a personal physician; and
Rising health costs do not bankrupt the country, employers and
We believe that the Affordable Care Act (ACA) has policies that
are absolutely essential to address these challenges. It
must not be repealed.
But no legislation is perfect. President Obama, in his State of
the Union address to Congress, said he is willing to consider
"ideas about how to improve this law by making care better or more
Mr. President, we agree with you, and hope that both political
parties will work together to make the law better.
Yet conventional wisdom tells us that unrelenting political
conflict over the Affordable Care Act appears to be the order of
Republicans are committed to the ACA's repeal and Democrats are
committed to keeping it intact.
The simple fact, though, is that neither side can win this
fight. The law won't go away, as most Republicans hope, but
restrictions on funding and enforcement could undermine its
effectiveness, as many Democrats fear.
We could end up with a law that remains on the books- along
with all of its controversial mandates, like the requirement that
people buy insurance-but without the funding needed for it to
work well for American families. For instance:
The law might prohibit insurance companies from excluding or
over-charging people with pre-existing conditions, but many
Americans could still be turned away if Congress doesn't give
federal agencies the money needed to enforce the rules.
The law might guarantee access to coverage, but if Congress
doesn't fund the ACA's programs to train and retain more primary
care physicians, patients will wait longer for appointments,
leading to delays in getting needed treatment, poorer outcomes, and
The American College of Physicians (ACP) firmly believes that
the United States must not go back on expanding coverage, training
and retaining primary care physicians, and beginning to "bend the
cost curve." Our report, which is included in your press packet and
is online, identifies many essential programs established by the
ACA to address such challenges.
Keeping these programs on the books is not enough; they also
need to be funded. The law's "discretionary" programs-meaning that
they are subject to annual appropriations-are particularly
vulnerable to cuts, given the pressure to cut federal spending on
Programs like the Title VII health professions training
programs, which have proven track records in getting more primary
care physicians trained and working in underserved areas.
Such programs need to be funded at no lower than the levels
authorized by the ACA.
Otherwise, the country will spend much more because of a growing
shortage of primary care physicians. Research tells us that having
an adequate number of primary care physicians in a community is
positively associated with better outcomes and lower costs.
Many "mandatory" programs might also be vulnerable to Congress
placing restrictions on effective enforcement by federal agencies,
Programs to expand coverage, including tax credits for small
businesses and families and money to states to set up health
exchanges and enroll more people in Medicaid.
Higher Medicare and Medicaid payments to primary care
Comparative effectiveness research to inform clinical
In addition, financial incentives for physicians to meaningful
use certified electronic health records to improve patient outcomes
could be at risk. Such incentives are included in the American
Recovery and Reinvestment Act (ARRA) and could be considered to be
among the unspent "stimulus" dollars that House Republicans have
pledged to eliminate.
The threat that Congress might cancel the incentive program will
discourage physicians from moving forward on health information
technology investments, and could pull the rug out on those who
have already invested tens of thousands of dollars in the
expectation that they will qualify for the incentive payments.
Yet many of the specific programs that appear to be vulnerable
have had a long legacy of bipartisan support, which we hope will
carry over into the 112th Congress. The goal of everyone having
access to electronic health records within 10 years was first set
by a Republican president, George W. Bush, in his 2005 State of the
Union speech to Congress. Ever since then, Congress has worked
together on a bipartisan basis to advance this goal.
Republicans and Democrats alike have also supported reforms to
support the value of primary care. Legislation to authorize
Medicare pilots of Patient-Centered Medical Homes, for instance,
originated in the GOP-led 109th Congress.
We know that bipartisan solutions remain possible, if we can
move beyond arguing about repeal, to seeking common ground to
build and improve upon the Affordable Care Act.
Let me suggest five such areas:
First, Congress and the White House should seek common ground
on giving states more options sooner.
Today, ACP is pleased to announce its support for the Empowering
States to Innovate Act, introduced in the 111th Congress by
Democrat Ron Wyden and Republican Scott Brown. This bill would give
states the option to seek waivers, three years earlier than now
permitted by the ACA, to design their own programs to expand
coverage, free of many of the law's mandates, as long as they could
provide affordable and sufficient cover to at least as many
We also call for modifying the ACA to allow states to enter in
an agreement for insurance to be sold across state lines, two years
earlier than the current effective date of 2016.
Second, Congress and the White House should seek common
ground on replacing Medicare's sustainable growth rate (SGR)
formula with a new framework.
This new framework should ensure stable and positive updates for
all physicians, provide additional increases for undervalued
primary care services, protect payments for primary care from being
reduced due to volume increase in other categories of services, and
create incentives for physician practices to become
Patient-Centered Medical Homes.
Third, Congress and the White House should seek common ground
solutions to reduce health care costs.
They should start by agreeing to support the programs authorized
by the ACA that have the greatest potential to lower costs and
It makes no sense, for instance, for fiscal conservatives to
want to eliminate funding for comparative effectiveness research to
help patients and their doctors make better choices based on
evidence, or to reduce funding for Medicare and Medicaid pilots to
align incentives to clinicians with value.
Fourth, Congress and the White House should seek common
ground on effective approaches to reduce the costs of defensive
We are encouraged that President Obama, in his State of the
Union remarks, promised to "look at other ideas to bring down
costs, including one that Republicans suggested last year --
medical malpractice reform to rein in frivolous lawsuits."
Mr. President, we agree that more needs to be done to fix a
broken medical liability system:
ACP is one of over 100 physician membership organizations that
have endorsed H.R. 5, the "Help Efficient, Accessible, Low-cost,
Timely Healthcare (HEALTH) Act of 2011," introduced by Rep. Phil
Gingrey. This bill includes caps on non-economic damages and other
reforms that have been proven to reduce the costs of defensive
We recognize, though, that caps aren't the only or entire
solution. Today, ACP calls on Congress to enact legislation to
allow for pilot-testing of health courts on a national scale.
Health courts are a no-fault system that would have cases heard
by specially trained judges, who would have access to independent
medical experts. The judges would be empowered to rule on the
merits of claims and to authorize awards commensurate to the actual
Fifth, as Dr. Ralston has so eloquently described, both
political parties must confront the reality that we can't spend
unlimited amounts of money on health care.
We need to have a national conversation on how to conserve and
share health care resources effectively, efficiently, judiciously,
and fairly, based on the evidence of their clinical effectiveness
and value, and in accord with distinctive American values including
To start this conversation, ACP proposes key elements that
should be considered in making such decisions, including empowering
people to make decisions based on the best evidence of value and
ensuring broad input from the public and all affected
We understand the challenges involved in reaching consensus on
conserving and allocating health care resources, but beginning this
conversation now can help the United States avoid the explicit
limits on care that exist in other countries.
Let's now return to the politics. As I said at the beginning,
the conventional wisdom is that we can expect nothing more from
Congress over the next two more years other than unrelenting
conflict over repeal of the Affordable Care Act.
The conventional wisdom might be right, but we must insist on
The problems facing American health care are too great to have
two more years of political wrangling that will lead to gridlock,
or even worse, an under-funded and poorly implemented Affordable
Former Senate Majority Leader Bill Frist, a Tennessee Republican
and heart surgeon, recently said this:
"The reality is that the law will remain largely intact. . .
That being the case, it is important that it be made to work as
effectively as possible . . . there are lots of things that can be
fixed or modified by working together."
Dr. Frist, we agree with you.
In today's State of the Nation's Health Care report, ACP
proposes specific ways to build and improve upon the ACA: give
states more options, reduce the costs of defensive medicine,
replace the Medicare SGR formula, improve payments for primary care
services, and initiate a broad national discussion on conserving
health care resources.
We hope others will join us in challenging our elected leaders
to find common ground solutions to sustain, build and improve upon
the ACA's essential policies on coverage, capacity and costs,
considering ideas from across the political spectrum and from
America's internal medicine physicians.
Dr. Ralston and I would be pleased to answer your questions.